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John P. Goodman DDS

Understanding Dental Insurance Part 1: "Reasonable and Customary" Fee Schedules

By Dr. John Goodman on May 02, 2012

At the Kansas City dental office of John P. Goodman DDS, we acknowledge that understanding dental insurance coverage and benefits can be confusing, time-consuming, and complicated.  We accept many dental insurance plans and strive to assist in the comprehension of each patient's dental policy.  With that stated, one must know that you, as the policy holder are the responsible party for the filing of dental claims with your insurance as well as any charges for services at any dental office.  As a courtesy to our beloved patients, Dr. Goodman and friendly staff will file claims with your insurance company and assist as far as we can in the process.  Unlike other offices, even if your insurance is considered out of network we will still verify and attempt to process your claim with your insurance (except medicaid/medicare plans).

The Difference in Insurance and Dentist Fee Schedules

Insurance benefits are sometimes difficult to understand due to multiple factors of determining amounts of coverage based on the dental service.  Dentists and practice owners have to keep a competitive fee schedule to ensure business and keep up economically.   An insurance company's goal is to hold on to their money for as long as possible.  Their fee schedules have had little to no increase over the last several decades.  This gives dentist's fee schedules an overpriced impression and is known to create animosity between the dentist and patient.  Insurance companies call this fee schedule,  "reasonable and customary" fees.  This translates into what they will pay on those services provided by a dentist office in a specific region. 

Kansas City Dentist-Dental Insurance

(Not only is there animosity from the difference in fee schedules, but the entire process of filing a claim can be difficult as well.  Sometimes the insurance company will say they never received a claim, when in fact it is sitting in the trash or on someone's desk.   Our office strives to prevent this occurrence by verifying your benefits before or during your first visit, estimating coverage for services, filing your claim and following up to ensure processing.  This can include, but is not limited to electronic filing, mailing, faxing, and several phone calls with long wait times to your insurance company.  Keep in mind, insurance takes on average thirty days to process a claim and for dental offices to receive payment.  In some cases, that’s thirty days the dentist goes without payment for your services.)

 

Reasonable and Customary Fee Schedule

Understanding the difference between insurance "reasonable and customary" fee schedules and the dentist’s fee schedule is important when attempting to predict your insurance benefits at any dental office.  Dental insurance benefits are always “estimated, not guaranteed”.  Estimated benefit amounts from the insurance are given, but tend to be vague.  Unlike many offices, our dental office will attempt to determine a more realistic estimated benefit amount.  We don’t mind going the extra step to make sure you hold on to your time and money. 

To determine benefit amount, one must look at the dentist's fee for the service compared to the insurance companies reasonable and customary fee schedule and the percentage of coverage on that service.  Dental services are divided by insurance companies into percentages of coverage under preventative, basic and major service categories.  These percentages, other than those estimated being covered at 100% are almost always accompanied by an out of pocket deductible and co-pay due at the time of service to the dentist office. 

In Network Benefits

At the office of John P. Goodman DDS, our fees reflect the exceptional quality of service, innovative technology, materials, labs and equipment used to ensure the best experience for the patient.  If your dental insurance company is in network with John Goodman DDS, you are likely to receive additional benefits and write-off (discounts) at our office.  The write-off amount is the difference between our fee schedule and your insurance plan's fee schedule for the service. 

For Example: (If your insurance is in network with John P. Goodman DDS) and you receive an exam and x-ray at our office for $100, but your insurance only allows $72 payable on those services and you have 100% estimated coverage and your deductible is waved on those preventative services, then we write-off that difference and your out of pocket balance is $0.  Or, if you need a filling that costs $165, but your insurance only allows $100 and has a deductible of $50 to be met on basic services as well as 80% coverage, then your out of pocket balance is the deductible plus the remaining 20% ($20)of the allowable amount and we write off the difference between our fee and the insurance allowable amount ($65).

Out of Network

If your dental plan is out of network and allows these benefits to our dental office, you are usually responsible for the difference between the reasonable and customary insurance fee schedule and our fees.  It depends on the insurance company and your plan to whether or not they provide these benefits.  The easiest way to find out if your insurance provides out of network benefits is to look at your Insurance information packet, call the provider listing line on your insurance card, or some insurances even let you check your insurance plan online.  It is highly recommended to verify out of network benefit before coming to our office if we are not listed as a preferred provider with your insurance company. 

We hope this helps to have a better understanding of your insurance plan.  If you have any questions you can give our friendly staff a call or refer to your dental insurance company and providing employer for more information about your policy.

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2700 Clay Edwards Dr
Ste 570
Kansas City, MO 64116

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